a client is admitted with ascites malnutrition and recent complaints of spitting up blood what assessment finding warrants immediate intervention by t
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A client is admitted with ascites, malnutrition, and recent complaints of spitting up blood. What assessment finding warrants immediate intervention by the nurse?

Correct answer: C

Rationale: A round and tight abdomen suggests fluid accumulation from ascites, which could signal a more severe underlying condition requiring immediate intervention. This finding indicates increased intra-abdominal pressure, which can lead to respiratory compromise or other serious complications. Capillary refill time, bruises on arms and legs, and pitting edema in the lower legs are important assessments but do not directly indicate the need for immediate intervention as a round and tight abdomen does in this case.

2. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?

Correct answer: C

Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.

3. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective and must be reported by the nurse immediately to the healthcare provider?

Correct answer: B

Rationale: A fever of 103 degrees Fahrenheit indicates that the infection is not under control despite antibiotic therapy. Fever is a common sign of ongoing infection or inadequate response to treatment. Nausea and vomiting, diffuse macular rash, and muscle tenderness are not typically indicative of the effectiveness of antibiotic therapy in treating infective endocarditis.

4. A client with a colostomy is being discharged. What teaching is most important for the nurse to provide?

Correct answer: C

Rationale: The most important teaching for a client with a colostomy is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining the proper seal of the pouching system. Changing the ostomy bag daily (Choice A) is not necessary unless it leaks or becomes loose. Avoiding gas-producing foods (Choice B) is essential for some clients but is not the most important teaching. Using a skin barrier (Choice D) is important but not as crucial as emptying the ostomy pouch at the right time to prevent complications.

5. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

Correct answer: D

Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.

Similar Questions

A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?
What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
A nurse finds a pregnant client at 33 weeks gestation in cardiac arrest. What modification to cardiopulmonary resuscitation (CPR) should the nurse implement?
A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?
A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses